Prävention und Management von postoperativen Komplikationen in der Pankreaschirurgie

Zusammenfassung

Obwohl die Letalität in der Pankreaschirurgie durch Zentrumsbildungen in den letzten Jahrzehnten deutlich zurückgegangen ist, bleibt die Morbidität nach Pankreasoperationen hoch. Eine hilfreiche Unterteilung, die auch in der Literatur häufig gemacht wird, erfolgt in Pankreaskopf- und Pankreaslinksresektionen. Die Komplika­tions­raten beider Eingriffe sind hoch, bei der ­Pankreaskopfresektion jedoch häufiger mit Interventionsbedarf bei lebensgefährlichen Komplikationen vergesellschaftet. Zu den Hauptkomplika­tionen zählen die verzögerte Magenentleerung (delayed gastric emptying – DGE), Pankreasfisteln, Anastomoseninsuffizienzen und Blutungen. Aktuelle Studien zum Vergleich unterschiedlicher Anastomosen- bzw. Verschlusstechniken am Pankreas hinsichtlich der Komplikationsrate zeigen keine einheitlichen Ergebnisse. Das gleiche gilt für die perioperative Verwendung von Somatostatin und dessen Analoga zur Prävention von Komplika­tionen. Einigkeit besteht jedoch darin, dass das „weiche“ Pankreas und ein schmaler Pankreasgang < 3 mm Risikofaktoren für die Entstehung von Pankreasfisteln / Anastomoseninsuffizienzen sind. Ebenfalls geht der Trend eindeutig zur konservativen bzw. interventionellen Therapie von Pankreasfisteln und Abszessen durch verbleibende Dränage, Nahrungskarenz, Somatostatin-Gabe und ggf. CT-gesteuerte Dränagen-Anlage. Bei der gefürchteten Blutung nach Pankreas-Operation gehen die Mei­nungen über die therapeutische Versorgung aus­einander. Eine Unterscheidung wird hier in die ­frühe und späte postoperative Blutung gemacht. Das Management reicht von endoskopischer Blut­stillung über angiografisches Coiling / Stenting bis zur Re-Operation, wobei alle dieser Verfahren mit einer hohen Letalität behaftet sind. Dies ist eine Aufarbeitung der aktuellen Literatur zu diesem Thema mit der Darstellung verschiedener Algorithmen zum Komplikationsmanagement.

Abstract

During the last decades mortality after pancreatic surgery has decreased. Nevertheless, morbidity still remains at a high level. It is important to differentiate between pancreatic head resection and distal pancreatectomy. The complication rates of both procedures are high, however the need for intervention to manage perilous complications is higher after pancreaticoduodenectomy. The main complications after pancreatic surgery are delayed gastric emptying (DGE), pancreatic fistula, anastomotic leakage and bleeding. The current literature on the different techniques of pancre­atic anastomosis and pancreatic remnant closure, respectively, does not show consistent results or an advantage for a particular technique. The same is true for the perioperative use of somatostatin and its analogues for the prevention of complications. It is widely agreed that the smooth texture of the pancreas and a small pancreatic duct < 3 mm are risk factors for pancreatic leakage or fistula. Today, the trend is more for conserva­tive or interventional therapy for pancreatic fistulas or intraabdominal collections with, e. g., persisting intraoperative drain, TPN, somatostatin therapy or CT-controlled drainage. The opinions about the optimal treatment of the dreaded ­postoperative bleeding differ significantly in the surgical community. There are early and late bleedings and the management varies from endoscopical treatment or angiographic coiling / stent­ing to revision. Nevertheless, every bleeding is ­accompanied with high mortality. Here we present a review of literature and demonstrate the various strategies for the management of complications.

Schlüsselwörter

Pankreaschirurgie - Pankreaskopfresektion - Pankreaslinksresektion - postoperative Komplikation - Management postoperativer Komplikationen - Pankreasfistel

Key words

pancreatic surgery - pancreatic head resection - distal pancreatectomy - complications after pancreatic surgery - management of complications after pancreatic surgery - pancreatic fistula

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